interviews

High-risk approach

Far too many high-risk patients are dying after surgery, with few of them informed properly about the risks of having their operations, and fewer than half receiving care classed as ‘good’ or better. NHE speaks to NCEPOD’s Dr George Findlay

Knowing the risk’, the latest report by NCEPOD (the National Confidential Enquiry into Patient Outcome and Death), recommends the introduction of a UKwide system to rapidly identify high-risk patients ahead of surgery.

All high-risk patients having elective surgery should be seen in a pre-assessment clinic, and they must be told of the mortality risk associated with their operation. Trusts must better cater for high-risk patients and provide proper post-operative care, the report says.

Report co-author Dr George Findlay, NCEPOD clinical co-ordinator and intensive care consultant, said there is a real lack of understanding among clinicians of the real risks of surgery for some patients.

He said: “It’s not just the risk of death and complications, but also the effect that has on patients’ length of stay and resource utilisation. If you talk to clinicians as we have been doing, and talk to surgeons, they don’t really have a true appreciation of the risk that some of their patients face. We therefore don’t really do the right thing for those patients, and so they stay in hospital an awful lot longer, they do badly, and they use lots more bed days than they need to.

“If we got the system working better, there would be so much more capacity to treat patients. Maybe still not enough – we might need some additional resources to go in. But I couldn’t, with hand on heart, say that’s the root of the problem – the root is that the pathways aren’t right, the recognition of patient risk isn’t there, the management of patients according to that level of risk isn’t there, and the result is an inefficient system that’s not good for patients.”

The report’s finding that high-risk patients do not get enough information about the potential risks of surgery got a lot of media attention, and Dr Findlay said they need to know.

He said: “It would be incredibly paternalistic not to tell people what the chance of them dying from a procedure is. There are some patients who undergo surgery and it hastens their death, because the complication rate and mortality rate is high, whereas if they’d chosen not to have an operation, whilst ultimately they will die, their time to dying may be longer. That’s really important.

“I’d be unhappy if we didn’t share information with patients about mortality risk, and also the likelihood of morbidity and poor outcomes. Many people undergo procedures deemed life-saving, and end up living another six or twelve months, but in a pretty debilitated, dependent state. When you speak to those patients, that’s not what they signed up to, or thought they signed up to – and not what they would have wanted.”

But getting a UK-wide system for identifying high-risk patients is not necessarily easy, depending as it does on the patient, the circumstances, and the surgery.

Dr Findlay said: “Some patients, having relatively minor surgery, say a hernia repair, may actually be very high-risk because of underlying factors – their age, frailty, heart disease, lung disease – so it’s often a combination of things that makes somebody high-risk. Sometimes it’s easy to define – if you’re having an oesophagectomy, or a major colonic resection, we know that puts you in a mortality group, even if you don’t look at any other facts.”

NCEPOD wants the medical Royal Colleges to come up with a UK-wide system to stratify risk. Dr Findlay said the ‘80-20’ rule applies – about 80% of high-risk patients are easy to identify based on their surgery or underlying conditions, but around 20% can slip through the net and not get the proper care or information.

Dr Findlay said the onus is on Trusts to improve things, and that they need to examine their data on procedures and patient outcomes to identify patients likely to do badly, die, or have long lengths of stay.

He said: “They need to focus on pathways of care for those people. Each hospital must identify high-risk patients and come up with a plan to deliver appropriate care for those people and quantify it, and pass that onto the Trust board or chief executive so they are aware of the responsibilities of the organisation.”

The real worry is that things may actually be getting worse.

Dr Findlay explained: “If you look at emergency NCEPOD theatre provision, there’s less now than there was a few years ago, and our feeling is that as Trusts are more focused on delivering elective waiting times targets, they may be taking their eyes off the ball on emergency provision.

“We are concerned about emergency highrisk patients – if you have an intra-abdominal operation as an emergency, 1 in 4 people are dead within 30 days, for example.

“Patients may be getting a worse deal because of the focus on delivering elective targets, and the fact that everyone’s so constrained financially.”

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